Fundamentally, Safety Is a People Problem—An Overview

If you want to improve your company's safety performance, stop focusing on
your accident statistics, loss source analysis, traditional interventions, and
regulatory compliance and start thinking holistically. We need to look for and
find our answers in the elemental aspects of the organization.

Most companies create an output (a product or service). They have internal
systems (plant, tools, equipment, technology, policies, procedures, means, and
methods) with which to create that output and people to energize, operate, and
manage the systems. But first, we have to dispel some myths about the
management of safety before tackling the improvement effort.

Figure 1: Elemental Aspects of an Organization

The belief that regulatory compliance ensures positive safety results is
something of a myth. Complying with Occupational Safety and Health
Administration (OSHA) standards does not necessarily ensure you have a safe
workplace. Virtually all things covered in the safety standards are conditions
focused and managed by site inspections and engineering controls. Herbert
William Heinrich's maxim that the vast majority of accidents is caused by
unsafe acts provides a clue to the problem with OSHA compliance.

H.W. Heinrich's research found that 10 percent of accidents were caused
by unsafe conditions, while 88 percent were caused by unsafe acts. Since the
standards concentrate on the 10 percent portion of the sources of accidents,
there is little chance of truly improving safety performance. Dr.
Heinrich's research was reaffirmed by a later study conducted by Frank E.
Bird, which attributed 5 percent of accidents to conditions and 95 percent to
unsafe acts. Given this, how much improvement do you think we can get with the
traditional approach to safety management?

This does not mean that the safety standards have no value. Of course not!
They have had some effect in improving the overall occupational safety
statistics. This improvement was mostly achieved by making the worst companies
better, but they have done little in improving the safety performance of the
good companies. If we are truly serious about dramatically improving our safety
outcomes, we need to identify and explore more effective means for achieving
better results.

Improving Safety Conditions

The first axiom in Dr. Heinrich's book, Industrial Accident
Prevention, first published in 1931, stated that accidents are caused by
unsafe acts and conditions. Let's look at the conditions part of this
statement. To get injured, there usually needs to be an unsafe condition to
which the worker is exposed; then the worker needs to perform the unsafe act.
Had the unsafe condition not existed, the worker might not have been injured.
So, why was the unsafe condition present? Behind every unsafe condition, there
is a management system that allowed it to occur and exist. More on this
later.

Next, let's look at the premise that accidents are mostly caused by
unsafe acts. This has resulted in focusing on the worker to improve safety
performance outcomes since it is the worker who gets injured after all. This
has spawned a number of interventions. If you look at the safety standards,
there are numerous instances where training is required. This is to familiarize
workers with the standards. The underlying premise is that, armed with this
knowledge, the worker will perform the work in a safer manner. In practice, to
this end, there are toolbox talks, safety meetings, training sessions, signs
and posters as reminders, feedback, observations, etc. All of these are there
to change the worker's behavior. Despite all these tools, workers still get
injured. So there must be other factors at play that are not effectively
addressed by these interventions.

To devise improvement, interventions loss data is usually analyzed. This
information primarily comes from accident investigation reports submitted to
the insurance company. These reports are reviewed by claims personnel, who
assign a cause label and enter the information into their database. The focus
of claims is quite different from that of accident prevention, so using claims
data does not necessarily provide operationally effective intervention
information. But safety improvement interventions usually use this information
to formulate improvement strategies. Safety improvement strategies need
information on why the person did what they did much more than how and when
they were injured so as to come up with an operationally effective prevention
strategy. By focusing on unsafe acts and conditions, organizations end up
dealing with accidents on a symptomatic rather than at the causal level.

There are the metrics used to measure and manage safety performance. The
prevailing measures of safety performance are the frequency of accidents and
their severity (mainly, the total recordable and the "Day Away,
Restricted, Transferred" rates). This sort of data might provide general
information on performance compared to previous years or Bureau of Labor
Statistics published values, but they have little correlation to business
metrics. Namely, they provide no direct evaluation of the efficiency or value
of any particular intervention or how any of this contributed to operational
effectiveness or return on the invested resources. Because safety management
has devised unique measures that aren't very meaningful to senior
management, these executives have concluded that the techniques that work for
improving quality, productivity, or partner relations are not applicable for
safety improvement because it's somehow different.

Illustration

I was asked to get involved in a situation where a residential framer, who
was at a 140 percent loss ratio, vehemently disagreed with the loss control
consultant's recommendations for reduction of its accident rate and, as a
result, their cost of risk. The insured's most significant problem areas
were a very high incidence of workers getting injured while carrying material,
injuries from falls, and injuries from access issues. The loss data used by the
insurance consultant came from his vast claims database.

Of greatest concern to the underwriter, who reviewed the claims data, was
that this risk's manual material handling claims ran about twice that of
its book for similar businesses. He dispatched the loss control consultant to
address this issue. The consultant's recommendation was to use mechanical
aids (such things as pallet jacks, dollies, etc.) in its material handling
process. The insured maintained that these recommendations were impractical,
which led to my involvement.

After reviewing and discussing the circumstances around a number of these
accidents, it became evident that, while carrying materials (mostly beams,
joist, and plywood), the workers tripped on debris on the floor. This resulted
in a housekeeping recommendation that addressed the underlying problem and was
operationally feasible. In fact, the framer stated that, even though cleanup
was not his responsibility, its cost was by far much less than the savings he
would realize in insurance costs as well as operational efficiencies, and he
would have an avenue to either get the developer to do it more effectively or
collect the cleanup cost from it.

Changing Processes

Accidents are rare events. There is research that shows a worker can work
5–7 years before having an accident. Engaging in unsafe acts does not routinely
or necessarily result in accidents. This leads to acceptance of such acts as
normal practice. For most organizations, particularly smaller ones, recordable
injury rates have little statistical validity. They neither diagnose nor fix
what went wrong. They also have very little value in providing
"real-time" information leading to operational solutions. Moreover,
injury statistics are downstream measures, and what is really needed are
upstream operational measures that tell you what is going on or whether your
systems, practices, procedures, and processes are getting any better going
forward due to any changes instituted.

Another fundamental problem is the fact that organizations implement
interventions (audits, inspections, training, incentives, feedback, punishment,
etc.) based on an analysis of the previous year's loss data. After
implementation, they have no good indication of what really worked or to what
extent any of these interventions truly had an impact on the outcomes. There is
little or no correlation between the inputs and the outcomes. This leads to
repeating potentially ineffective improvement measures, such as priority or
emphasis programs, which at best are ineffective or useless at worst.
Organizations cannot afford to misuse time and valuable resources without
positively impacting operational efficiency and/or the bottom line.

In larger organizations where there are multiples divisions, business units,
sites, or projects, the safety performance of these entities usually varies.
Some have lower losses than others despite the fact that they all adhere to the
same organizational policies as well as use the same safety program. They all
have safety meetings, perform job safety analyses, engage in safety planning,
conduct daily site inspections, and require subcontractors to hold weekly
toolbox talks. The sites with the higher losses get attention, while the others
are pretty much left alone. This does not make any sense, as all locations can
improve, and the good ones certainly can get better. The question should be why
these techniques are more effective in some locations than in others. This
apparent variability, to some extent, has to do with the effectiveness of
planning and the execution of the program on the part of the people at the
various locations.

Examining Personnel

Let's look at the people involved. There is the worker who gets injured
and the supervisor (foreman) who oversees the crew. The other people involved
are the superintendent and project manager responsible for the site. And, of
course, there are all the people at the main office. Effectively, there are
three management levels plus staff (supervision, middle managers, and
executives) who can and should exert influence on the safety outcome. Yet,
traditionally, it is the worker who is the focus of the effort and the safety
(practitioner/professional) person who tries to remedy the situation. This does
not make sound operational sense and adversely impacts the business.

The worker should try to work safely, use good judgment and practices,
utilize relevant information, pay attention to the task at hand, certainly be
aware of the work environment, and try to be efficient and effective as well as
productive. Despite all that, the worker is still human and prone to make
mistakes. If management changes (reduces) the risk picture, the resulting
outcomes should be better. If the worker is somehow deficient, is not capable,
or does not have the knowledge or motivation, then it is management who did the
hiring. Having a robust hiring practice, which excludes
"unacceptable" workers, is a management responsibility. So, if
management hired a "deficient" worker, then they either should have
remedied the deficiency before making the task assignment or should have
assigned the worker to a task that he or she is capable of performing. Task
assignment is a management responsibility.

If the worker has "bad" habits, is a risk taker, is not prone to
follow directions, or has any other unacceptable traits that may not have been
apparent during the hiring process, then it is the supervisor who should
observe the worker's behavior and take action to remedy the situation or
remove the worker from the task. If the worker was a "good" performer
and somehow changed later (say, due to some personal issues), then again it is
the supervisor who should do something about the adverse situation to correct
it; otherwise, the occurrence of an accident is a foregone
conclusion.

In looking at the figure, one can see a distinct link between the various
systems at the different levels of the organization and the people who devised
and/or oversaw them, leading to the resulting unacceptable or unanticipated
outcomes. In construction, work in place is the output. Inefficiency, poor
quality, and injuries are outcomes, not outputs. They are a side effect of the
operational process that is influenced by the organizational systems and
management's goals and expectations. Unsafe conditions as well as the
unsafe acts may be caused by the worker's perception or understanding of
what is required or expected by management.

If the operation is conducted in a different way (change the task design,
modify the production goal, alter the task demand, revise the process, or
adjust the means or methods), or if management evaluates the level of the risk
and does something to reduce its severity, the outcome could be different. Much
of the process is devised and controlled by management. This is not to say that
all risk can be eliminated, but, with a robust risk assessment and planning
process, either a large percentage of the hazards can be eliminated or their
adverse outcome modified to acceptable levels. Those hazards that cannot be
eliminated or modified should be identified and discussed before any task
starts to see what additional measures to reduce the exposure or modify the
work process, task design, assignment, or any other mitigating procedure to
ensure minimization of loss can be taken.

To manage, you need to measure, and to measure, you need to have goals. All
companies have production, qualilty, and safety goals. It is a fact that
organizational metrics drive behavior. So, if there are multiple goals and
metrics, which there usually are, then there is the potential for confusion or
conflict. Some metrics are easier to come by than others are. Production
metrics become readily apparent and are easily observed. This can be measured
on a daily, even hourly, basis. Quality results are not as readily apparent,
and safety results are even more difficult to effectively measure on a daily
basis.

When it comes to goals, there is the belief that "stretch" goals
are a good thing. They motivate the worker to try harder or use ingenuity to do
better. This is true to some extent, but successive "stretch" goals
eventually put the worker at a point where he or she reaches maximum capacity,
and no amount of discretionary effort will increase output. This is the point
where the worker may have to make a choice between production and safety. Since
the worker generally needs to work, and a shortcut (unsafe act) may increase
productivity, the choice is a no-brainer! This is a system-driven risk!

Behind every unsafe act, there is a reason that caused the worker to make a
decision that resulted in the unsafe behavior. In most cases, there is a
management policy or practice that leads the worker to perceive he or she is
making a choice that management wants or expects. This may or may not be the
case, but perception becomes reality, which can potentially cause unexpected or
unwanted outcomes. To be "successful," the worker has to function
within the systems of the organization. Many of the behaviors and risks taken
are a result of this symbiotic relationship. Therefore, to structurally
eliminate risks (hazards) from the organization's systems, management must
ensure that all the systems are integrated and the practices are aligned with
the business goals.

To solve the safety problem, we primarily have to look at the
"management" people much more than we do at the "worker"
people. We have to find our solutions at the organizational level and not the
unsafe condition or act level. It is the management people who define the
values and create the culture that delineates the norms, symbols, rituals,
artifacts, heroes, and stories. We must assess the climate to see what is
deemed acceptable and what is not. We have to look at the people in the
organization and the systems they devised to drive it. How much emphasis is
placed on leadership as opposed to management? Is safety an intrinsic part of
everything that is planned and done? It is leadership that inspires excellence
while management stresses achieving goals. Are people put into situations where
they have to choose between production goals and safe work practices? We have
to determine why workers do what they do and how the organizational systems
allow or even encourage such actions. Until we get to that causal level, we are
not going to get very far in improving our safety results.

There is another issue to note. Unless we eliminate the systems that allowed
risk to enter into the operations as well as allowed it to exist, intervention
focused on changing or removing a worker will not effectively solve the
problem. The system will eventually "get" the next worker and then
the next and the next and so on. Therefore, management must be vigilant to
ferret out any possible situation that may cause confusion or is open to
misinterpretation. Clear communication of objectives can play a big part in
avoiding confusion. The organizational metrics, how people are measured and
rewarded, the culture of the organization, and the work climate all may lead
the worker to thinking that unsafe behavior is okay. Excess pressure to achieve
goals or to meet the schedule increases stress and may lead to errors resulting
in inferior work quality or worker injuries.

Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

Like This Article?

IRMI Update

Dive into thought-provoking industry commentary every other week,
including links to free articles from industry experts. Discover practical
risk management tips, insight on important case law and be the first to
receive important news regarding IRMI products and events.